What is the recommended dosage of pantoprazole (proton pump inhibitor) for a child with a gastric ulcer?

Pantoprazole Dosing for Pediatric Gastric Ulcer

For children with gastric ulcers, use weight-based pantoprazole dosing: 1.2 mg/kg once daily (maximum 40 mg) for children ≥5 years of age, given before breakfast for 4-8 weeks. 1

Weight-Based Dosing Algorithm

For Children ≥5 Years of Age:

• Children weighing ≤12.5 kg: Administer 15 mg once daily 1
• Children weighing >12.5 kg to <25 kg: Administer 20 mg once daily 1
• Children weighing ≥25 kg: Administer 40 mg once daily 1

Treatment Duration:

• Initial treatment: 4 weeks, with extension to 8 weeks if ulcer has not healed 2, 3
• Healing rates: Expect 88% healing at 4 weeks and 97% healing at 8 weeks with pantoprazole 40 mg once daily 2

Critical Age Restrictions

Pantoprazole is NOT indicated for children <5 years of age because no commercially available dosage formulation is appropriate for this age group, despite clinical trial data supporting efficacy in children 1-5 years old. 1

• For children 1-5 years with documented erosive esophagitis (not simple ulcers), the studied dose was 1.2 mg/kg equivalent (15 mg for ≤12.5 kg, 20 mg for >12.5 to <25 kg), but this remains off-label due to formulation limitations 1

Administration Instructions

• Timing: Give once daily before breakfast for optimal acid suppression 2, 3
• Formulation considerations: The lack of appropriate formulations for children <5 years is a major limitation, as pantoprazole tablets/capsules cannot be easily modified for young children 1

Alternative PPI Options for Younger Children

If treating children <5 years where pantoprazole formulations are inadequate, consider omeprazole instead:

• Children 10 to <20 kg: Omeprazole 10 mg once daily 4
• Children ≥20 kg: Omeprazole 20 mg once daily 4
• Advantage: Omeprazole capsules can be opened and pellets mixed with applesauce for easier administration in children unable to swallow capsules 4

Comparative Efficacy Context

• Pantoprazole 40 mg once daily demonstrates superior healing rates compared to ranitidine and equivalent efficacy to omeprazole 20 mg once daily for gastric ulcers 2, 3
• Pain relief occurs in 79% of patients by 2 weeks and 88% by 4 weeks with pantoprazole 40 mg 2

Common Pitfalls to Avoid

• Do not use pantoprazole in infants <1 year: A randomized controlled trial in infants 1-11 months showed pantoprazole was NOT effective for symptomatic GERD, and it is not indicated for this age group 1
• Do not extrapolate adult dosing: Children have different pharmacokinetics, with highly variable plasma concentrations requiring weight-based approaches 1
• Ensure adequate treatment duration: Do not stop therapy before 4 weeks; extend to 8 weeks if healing is incomplete 2, 3
• Monitor for dose-dependent effects: While 20 mg shows efficacy, 40 mg provides more consistent acid suppression with less inter-individual variability 5

Safety Monitoring

• Pantoprazole is well tolerated in children, with adverse event rates of approximately 10% (similar to adults) 2
• Most common adverse events include diarrhea (1.5%), headache (1.3%), and dizziness (0.7%) 3
• Moderate increases in fasting serum gastrin occur but stabilize after one year of therapy 6